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Frequently Asked Questions on Mental Health Benefits in Connecticut
The Connecticut Insurance Department wants to remind consumers about Connecticut’s laws on mental health parity as well as the federal mental health parity laws, including the recent Wellstone –Domenici amendments to federal law. As background, Connecticut has had mental health parity insurance laws in effect for specified individual and group health insurance policies since 2000.
Below are questions and answers that the Department hopes will help consumers to better understand their rights to mental health benefits under health plans.
- What types of health insurance policies and plans are required to provide mental health benefits?
Federal law generally affords mental health protections for employer groups of 51 or more employees, when the employer provides mental health benefits under their medical benefit plan.
Connecticut’s mental health laws expand on the federal protections and extend protections to a wider range of plans including individual health policies and fully insured Connecticut group health insurance policies of all sizes (small and large employers). Policies providing coverage for hospital expense coverage, medical-surgical expense coverage, and major medical expense coverage, as well as HMO hospital and medical coverage agreements, that are issued in Connecticut, must include these important safeguards.
- What benefits must be provided?
Plans subject to Connecticut laws must contain two primary requirements:
- The policy must cover mental health benefits, meaning that mental health benefits cannot be excluded from the policy.
- The policy cannot establish any terms, conditions or benefits that place a greater financial burden on an individual to obtain mental health benefits than for diagnosis and treatment of medical benefits.
- How is the term “mental and nervous conditions” defined under Connecticut insurance laws?
The term is broadly defined to include all mental disorders included in the most recent edition of the “Diagnostic and Statistical Manual of Mental Disorders” published by the American Psychiatric Association. The publication is a comprehensive up-to-date list and classification of all mental disorders in the U.S. for both adults and children and is widely used throughout the country by mental health professionals.
- What conditions would not qualify as mental and nervous conditions under Connecticut insurance laws?
The following conditions are not covered: (1) mental retardation, (2) learning disorders, (3) motor skills disorders, (4) communication disorders, (5) caffeine-related disorders, (6) relational problems, and (7) additional conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders.”
- Do the state laws apply to self-insured plans?
No, the state laws only apply to insured plans. Self-insured plans are subject to the federal mental health laws. The federal laws do not require an employer to provide mental health benefits, but generally provide that if an employer voluntarily chooses to provide mental health benefits, it must do so on a parity basis with medical benefits. Also, under the federal law, certain plans may seek an exemption from mental health parity rules on a cost basis, if compliance with federal mental health parity increases claims by at least 2% in the first year and 1% in subsequent years. For consumers covered through their employer’s self-insured plan, please click on the following link for information:
http://www.cms.gov/HealthInsReformforConsume/04_TheMentalHealthParityAct.asp
- Are there any plans to which both the state and federal laws apply?
Yes, the federal law applies to employers with 51 or more employees whether the employer purchases a group health insurance policy or chooses to self-insure. If the employer self-insures, only the federal laws are applicable, as noted in Question No. 5 above. However if the employer with more than 50 employees chooses to purchase a Connecticut group health insurance policy, the plan is subject to both state and federal laws.
- What copayments may my health plan charge for visits to see a mental health professional?
Individual and Small Group – Under Connecticut insurance law governing individual policies and group policies issued to employers with 50 or fewer employees, health plans may charge a specialist copayment for office visits to a mental health professional.
Employers with 51 or more employees - under federal rules, for those plans which have a higher office visit copayment for specialists, generally the copayment for office visits to a mental health professional should be the same as the copayment for a visit to a primary care physician, rather than the copayment for a visit to a specialist. There is an exception to this rule, however, for those plans which have an actuarial determination demonstrating that they meet the “predominant” and “substantially all” tests specified in the federal rules.
- If I have further questions about mental health benefits under my health insurance policy or HMO coverage, where can I go for assistance?
Consumers interested in having the Connecticut Insurance Department review an insurance complaint or consumers who have questions about their individual insurance situation, may contact us for assistance:
Connecticut Insurance Department
Consumer Affairs Division
(800) 203-3447 – Toll Free from Outside Hartford
(860) 297-3900 – Direct Line
Email: ca.cid@ct.gov
Department website: www.ct.gov/cid
Content Last Modified on 8/8/2011 3:34:55 PM
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